Purpose of Medication: I understand that the prescribed medication is a compounded weight loss medication intended to aid in weight reduction. I understand that this medication is part of a comprehensive weight loss plan, which may include dietary changes, exercise, and behavioral modifications.
Compounding: I acknowledge that the medication prescribed to me has been compounded by a licensed pharmacy, meaning that it is a custom formulation created based on my individual needs. I understand that compounded medications may not be FDA-approved, though the individual ingredients are FDA-approved for other uses.
Risks and Side Effects: I understand that the use of compound weight loss medications may involve potential risks and side effects. These can include but are not limited to: - Increased heart rate - Elevated blood pressure - Dizziness or fainting - Gastrointestinal disturbances (nausea, vomiting, diarrhea) - Sleep disturbances (insomnia) - Headache - Mood changes (anxiety, depression) - Allergic reactions I agree to inform my healthcare provider if I experience any side effects or unusual symptoms.
Benefits: I understand that weight loss medications may help me achieve my weight loss goals, which could improve my overall health, reduce the risk of chronic diseases such as diabetes, hypertension, and heart disease, and improve my quality of life. However, I also understand that results are not guaranteed and vary from person to person.
Medication Use: I agree to use the medication only as prescribed and follow my healthcare provider’s instructions regarding dosage and duration. I understand that misuse or overuse of the medication can result in serious health risks.
Follow-Up: I understand the importance of regular follow-up appointments with my healthcare provider to monitor my progress and adjust my treatment plan as necessary. I agree to attend scheduled follow-up visits and communicate any concerns or changes in my condition.
Patient’s Name Printed:
Patient’s Name Signed:
Date:
Provider’s Name Printed: Dr. Hanan Hussein and her team associates
